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Trajkovski AV, Reiner K, Džaja N, Mamić G, Mažar M, Peršec J, Gluncic V, Lukic A. Anesthetic management for cesarean section in two parturient with ascending aortic aneurysm: a case-based discussion. BMC Anesthesiol 2024; 24:169. [PMID: 38711027 DOI: 10.1186/s12871-024-02553-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/30/2024] [Indexed: 05/08/2024] Open
Abstract
BACKGROUND The anesthetic management of parturients with ascending aortic aneurysm for cesarean section can be particularly challenging, primarily because of increased risk for aortic dissection or aneurysm rupture. CASE PRESENTATION We present some aspects of the anesthetic management of two parturients with ascending aortic aneurysm for cesarean sections; amongst, the use of remifentanil with its effects on patient and newborn. We emphasize the importance of a cardio-obstetric team in the context of preoperative planning of such patients. Also, we reviewed some literature on the anesthetic management with its effect on peri-operative hemodynamic stability. CONCLUSION Maintaining hemodynamic stability is paramount in the prevention of the rupture or dissection of ascending aortic aneurysm during labor of parturient.
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Affiliation(s)
- Ana Vuzdar Trajkovski
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Krešimir Reiner
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Nikolina Džaja
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Gloria Mamić
- Department of Anesthesiology, Perioperative Management and Intensive Care in Gynecology and Obstetrics, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Mirabel Mažar
- Department of Anesthesiology and Intensive Care in Cardiac and Vascular Surgery, Clinic of Anesthesiology, Reanimatology, Intensive Care and Pain Therapy, University Clinical Hospital Centre Zagreb, Kišpatićeva 12, Zagreb, 10000, Croatia
| | - Jasminka Peršec
- Clinic of Anesthesiology, Reanimatology and Intensive Care Medicine, University Clinical Hospital Dubrava, Avenija Gojka Šuška 6, Zagreb, 10000, Croatia
| | - Vicko Gluncic
- Department of Anesthesia, Advocate Illinois Masonic Medical Center, 836 W Wellington Ave, Chicago, IL, 60657, USA
| | - Anita Lukic
- Department of Anesthesia, Intensive Medicine, and Reanimation, Varazdin General Hospital, 1 I. Mestrovica Street, Varazdin, 42 000, Croatia.
- University North, Ul. 104. Brigade 3, Varazdin, 42 000, Croatia.
- Bjelovar University of Applied Sciences, Nursing Studies, 4 Eugena Kvaternika Square, Bjelovar, HR-43000, Croatia.
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Chen J, Chen S, Lv H, Lv P, Yu X, Huang S. Using part of the initial analgesic dose as the epidural test dose did not delay the onset of labor analgesia: a randomized controlled clinical trial. BMC Pregnancy Childbirth 2024; 24:254. [PMID: 38589777 PMCID: PMC11000377 DOI: 10.1186/s12884-024-06475-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/31/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND Epidural test dose for labor analgesia is controversial and varies widely in clinical practice. It is currently unclear whether using a portion of the initial dose for analgesia as the test dose delays the onset time of analgesia, compared to the traditional test dose. METHODS One hundred and twenty-six parturients who chose epidural analgesia during labor were randomly assigned to two groups. The first dose in group L was 3 ml 1.5% lidocaine, and in the RF group was 10 ml 0.1% ropivacaine combined with 2 μg/ml fentanyl. After 3 min of observation, both groups received 8 ml 0.1% ropivacaine combined with 2 μg/ml fentanyl. The onset time of analgesia, motor and sensory blockade level, numerical pain rating scale, patient satisfaction score, and side effects were recorded. RESULTS The onset time of analgesia in group RF was similar to that in group L (group RF vs group L, 7.0 [5.0-9.0] minutes vs 8.0 [5.0-11.0] minutes, p = 0.197). The incidence of foot numbness (group RF vs group L, 34.9% vs 57.1%, p = 0.020) and foot warming (group RF vs group L, 15.9% vs 47.6%, p < 0.001) in group RF was significantly lower than that in group L. There was no difference between the two groups on other outcomes. CONCLUSIONS Compared with 1.5% lidocaine 3 ml, 0.1% ropivacaine 10 ml combined with 2 μg/ml fentanyl as an epidural test dose did not delay the onset of labor analgesia, and the side effects were slightly reduced. CLINICAL TRIAL REGISTRATION http://www.chictr.org.cn (ChiCTR2100043071).
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Affiliation(s)
- Jianxiao Chen
- Department of Anesthesia, Shaoxing Shangyu Maternal and Child Health Hospital, 35 Banshan Road, Shangyu Block, Shaoxing, Zhejiang, China
| | - Sumeng Chen
- Department of Anesthesia, Obstetrics & Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu Block, Shanghai, China
| | - Hao Lv
- Department of Anesthesia, Shaoxing Shangyu Maternal and Child Health Hospital, 35 Banshan Road, Shangyu Block, Shaoxing, Zhejiang, China
| | - Peijun Lv
- Department of Anesthesia, Shaoxing Shangyu Maternal and Child Health Hospital, 35 Banshan Road, Shangyu Block, Shaoxing, Zhejiang, China
| | - Xinhua Yu
- Division of Epidemiology, Biostatistics and Environmental Health, School of Health, University of Memphis, 3770 Desoto, Memphis, USA
| | - Shaoqiang Huang
- Department of Anesthesia, Obstetrics & Gynecology Hospital of Fudan University, 128 Shenyang Road, Yangpu Block, Shanghai, China.
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Lau ES, Aggarwal NR, Briller JE, Crousillat DR, Economy KE, Harrington CM, Lindley KJ, Malhamé I, Mattina DJ, Meng ML, Mohammed SF, Quesada O, Scott NS. Recommendations for the Management of High-Risk Cardiac Delivery: ACC Cardiovascular Disease in Women Committee Panel. JACC. ADVANCES 2024; 3:100901. [PMID: 38939671 PMCID: PMC11198580 DOI: 10.1016/j.jacadv.2024.100901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 11/28/2023] [Accepted: 01/30/2024] [Indexed: 06/29/2024]
Abstract
Maternal mortality is a major public health crisis in the United States. Cardiovascular disease (CVD) is a leading cause of maternal mortality and morbidity. Labor and delivery is a vulnerable time for pregnant individuals with CVD but there is significant heterogeneity in the management of labor and delivery in high-risk patients due in part to paucity of high-quality randomized data. The authors have convened a multidisciplinary panel of cardio-obstetrics experts including cardiologists, obstetricians and maternal fetal medicine physicians, critical care physicians, and anesthesiologists to provide a practical approach to the management of labor and delivery in high-risk individuals with CVD. This expert panel will review key elements of management from mode, timing, and location of delivery to use of invasive monitoring, cardiac devices, and mechanical circulatory support.
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Affiliation(s)
- Emily S. Lau
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Niti R. Aggarwal
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
| | - Joan E. Briller
- Division of Cardiology, Department of Medicine, Obstetrics, and Gynecology, University of Illinois Chicago, Chicago, Illinois, USA
| | - Daniela R. Crousillat
- Division of Cardiovascular Sciences, Department of Medicine, Obstetrics, and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
| | - Katherine E. Economy
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Colleen M. Harrington
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kathryn J. Lindley
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
| | - Deirdre J. Mattina
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Marie-Louise Meng
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Selma F. Mohammed
- Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, USA
| | - Odayme Quesada
- Women’s Heart Center, The Carl and Edyth Lindner Center for Research & Education, The Christ Hospital Network Heart & Vascular Institute, Cincinnati, Ohio, USA
| | - Nandita S. Scott
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - ACC Cardiovascular Disease in Women Committee
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota, USA
- Division of Cardiology, Department of Medicine, Obstetrics, and Gynecology, University of Illinois Chicago, Chicago, Illinois, USA
- Division of Cardiovascular Sciences, Department of Medicine, Obstetrics, and Gynecology, University of South Florida Morsani College of Medicine, Tampa, Florida, USA
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Medicine, McGill University Health Centre, Montreal, Québec, Canada
- Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre, Montreal, Québec, Canada
- Division of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina, USA
- Division of Cardiology, Creighton University School of Medicine, Omaha, Nebraska, USA
- Women’s Heart Center, The Carl and Edyth Lindner Center for Research & Education, The Christ Hospital Network Heart & Vascular Institute, Cincinnati, Ohio, USA
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Schenone CV, Ashley Cain M, Schenone AL, Smith T, Tsalatsanis A, Louis JM, Crousillat DR. Changes in rate-pressure product associated with pregnancy. Am J Obstet Gynecol MFM 2024; 6:101338. [PMID: 38453019 DOI: 10.1016/j.ajogmf.2024.101338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/22/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND In nonpregnant individuals, the rate-pressure product, the product of heart rate and systolic blood pressure, is used as a noninvasive surrogate of myocardial O2 consumption during cardiac stress testing. Pregnancy is considered a physiological cardiovascular stress test. Evidence describing the impact of pregnancy on myocardial O2 demand, as assessed by the rate-pressure product, is limited. OBJECTIVE This study aimed to describe changes in the rate-pressure product for each pregnancy trimester, during labor and delivery, and the postpartum period among low-risk pregnancies. STUDY DESIGN This was a retrospective cohort study that assessed uncomplicated pregnancies delivered vaginally at term. We collected rate-pressure product (heart rate × systolic blood pressure) values preconception, during pregnancy for each trimester (at ≤13 weeks + 6/7 days, at 14 weeks + 0/7 days through 27 weeks + 6/7 days, and at ≥28 weeks + 0/7 days), during the labor and delivery encounter (hospital admission until complete cervical dilation, complete cervical dilation until placental delivery, and after placental delivery until hospital discharge), and during the outpatient postpartum visit at 2 to 6 weeks after delivery. We calculated the percentage change at each time point from the preconception rate-pressure product (delta rate-pressure product). We used a mixed-linear model to analyze differences in the mean delta rate-pressure product over time and the influence of prepregnancy age, prepregnancy body mass index, and neuraxial anesthesia status during labor and delivery on these estimates. RESULTS Our cohort comprised 316 patients. The mean rate-pressure product increased significantly from preconception starting at the third trimester of pregnancy and during labor and delivery (P≤.05). The mean delta rate-pressure product peaked at 12% and 38% in the third trimester and during labor and delivery, respectively. Prepregnancy body mass index was inversely correlated with the mean delta rate-pressure product changes (estimate, -0.308; 95% confidence interval, -0.536 to -0.80; P=.008). In contrast, neither the prepregnancy age, nor neuraxial anesthesia status during labor had a significant influence on this parameter. CONCLUSION This study validates the transient but significant increase in the rate-pressure product, a clinical estimate of myocardial O2 demand, during uncomplicated pregnancies delivered vaginally at term. Pregnant individuals with lower prepregnancy body mass index experienced a sharper increase in this parameter. Patients who receive neuraxial anesthesia during labor and delivery experience similar changes in the rate-pressure product as those who did not.
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Affiliation(s)
- Claudio V Schenone
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat).
| | - M Ashley Cain
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat)
| | - Aldo L Schenone
- Department of Internal Medicine, Albert Einstein College of Medicine, Bronx, NY (Dr A Schenone)
| | - Teagen Smith
- Department of Research Methodology and Biostatistics Core, University of South Florida Morsani College of Medicine, Tampa, FL (Ms Smith)
| | - Athanasios Tsalatsanis
- Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL (Dr Tsalatsanis)
| | - Judette M Louis
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat)
| | - Daniela R Crousillat
- Department of Obstetrics and Gynecology, University of South Florida Morsani College of Medicine, Tampa, FL (Drs C Schenone, Cain, Louis, and Crousillat); Division of Cardiovascular Sciences, Department of Internal Medicine, University of South Florida Morsani College of Medicine, Tampa, FL (Dr Crousillat)
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5
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Hart WM, Cobb B, Quist-Nelson J, Tully KP. Development and implementation of a pregnancy heart team at a Southeastern United States tertiary hospital: a qualitative study. Am J Obstet Gynecol MFM 2024; 6:101336. [PMID: 38453018 DOI: 10.1016/j.ajogmf.2024.101336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 02/15/2024] [Accepted: 02/27/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND The United States has seen a significant rise in maternal mortality and morbidity associated with cardiovascular disease over the past 4 decades. Contributing factors may include an increasing number of parturients with comorbid conditions, a higher rate of pregnancy among women of advanced maternal age, and more patients with congenital heart disease who survive into childbearing age and experiencing pregnancy. In response, national medical organizations have recommended the creation of multidisciplinary obstetric-cardiac teams, also known as pregnancy heart teams, to provide comprehensive preconception counseling and coordinated pregnancy management that extend through the postpartum period. OBJECTIVE We sought to describe the development and implementation of a pregnancy heart team for parturients with cardiac disease at a southeastern United States tertiary hospital. STUDY DESIGN This was a qualitative study that was conducted among healthcare team members involved during the pregnancy heart team formation. Semi-structured interviews were conducted between April and May 2022, professionally transcribed, and the responses were thematically coded for categories and themes using constructs from The Consolidated Framework for Implementation Research. RESULTS Themes identified included intentional collaboration to improve outpatient and inpatient coordination through earlier awareness of patients who meet the criteria and via documented care planning. The pregnancy heart team united clinicians around best practices and coordination to promote the success and safety of pregnancies and not only to minimize maternal health risks. Developing longitudinal care plans was critical among the pathway team to build on collective expertise and to provide clarity for those on shift to reduce hesitancy and achieve timely, vetted practices without additional consults. Establishing a proactive approach of specialists offering their perspectives was viewed as positively contributing to a culture of speaking up. Barriers to the successful development and sustainability of the pregnancy heart team included unmet administrative needs and clinician turnover within a context of shortages in staffing and high workload. CONCLUSION This study described the process of developing and implementing a pregnancy heart team at 1 institution, thereby offering insights for future multidisciplinary care for maternal cardiac patients. Establishing pregnancy heart teams can enhance quality care for high-risk patients, foster learning and collaboration among physician and nursing specialties, and improve coordination to manage complex maternal cardiac cases.
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Affiliation(s)
- William Michael Hart
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Hart and Cobb).
| | - Ben Cobb
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Hart and Cobb)
| | - Johanna Quist-Nelson
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Quist-Nelson and Tully)
| | - Kristin P Tully
- Department of Obstetrics and Gynecology, University of North Carolina at Chapel Hill, Chapel Hill, NC (Drs Quist-Nelson and Tully)
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6
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Vinsard PA, Arendt KW, Sharpe EE. Care for the Obstetric Patient with Complex Cardiac Disease. Adv Anesth 2023; 41:53-69. [PMID: 38251622 DOI: 10.1016/j.aan.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The prevalence of cardiac disease-related maternal morbidity and mortality is on the rise in the United States. To ensure safe management of pregnancy in patients with cardiovascular disease, pre-delivery evaluation by a multidisciplinary Pregnancy Heart Team should occur. Appropriate anesthetic, cardiac, and obstetric care are essential. Risk stratification tools evaluate the etiology and severity of cardiovascular disease to determine the appropriate hospital type and location for delivery and anesthetic management. Intrapartum hemodynamic monitoring may need to be intensified, and neuraxial analgesia and anesthesia are generally appropriate. The anesthesiologist must be prepared for obstetric and cardiac emergencies.
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Affiliation(s)
- Patrice A Vinsard
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Katherine W Arendt
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA
| | - Emily E Sharpe
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Chapman K, Njue F, Rucklidge M. Anaesthesia and peripartum cardiomyopathy. BJA Educ 2023; 23:464-472. [PMID: 38009139 PMCID: PMC10667612 DOI: 10.1016/j.bjae.2023.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/10/2023] [Indexed: 11/28/2023] Open
Affiliation(s)
- K. Chapman
- Royal Devon and Exeter Hospital, Exeter, UK
| | - F. Njue
- Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - M. Rucklidge
- King Edward Memorial Hospital, Subiaco, Western Australia, Australia
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Knapp C, Bhatia K, Columb M, Elriedy M. Remifentanil patient-controlled analgesia for labour in pregnant patients with heart disease. Int J Obstet Anesth 2023; 55:103902. [PMID: 37302184 DOI: 10.1016/j.ijoa.2023.103902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 05/22/2023] [Indexed: 06/13/2023]
Affiliation(s)
- C Knapp
- Department of Anaesthesia, Health Education England North-West, Manchester, UK
| | - K Bhatia
- Department of Anaesthesia, Saint Mary's Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - M Columb
- Intensive Care Unit, Wythenshawe Hospital, Manchester University Hospital NHS Foundation Trust, Manchester, UK
| | - M Elriedy
- Department of Anaesthesia, University Hospitals of Derby and Burton, Derby and Burton on Trent, UK
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